Imagine your kids are grown and living elsewhere. You recently had surgery to repair a heart valve and you fear you may end up in a wheelchair. You’ve developed cataracts and had to give up driving. Your lack of mobility makes you feel angry, isolated, and frustrated. You used to love going to church, playing cards with your friends, and taking in a new movie. But lately, you don’t care to spend time with anyone. You’ve even thought about killing yourself.

This isn’t as far-fetched as you might think. Although life is supposed to get better as we age, later-life suicide is a major public health priority. The American Association for Marriage and Family Therapy (AAMFT) reports that older adults make up 12.9 percent of the U.S. population, but account for 18 percent of all suicide deaths. And 2013 data from the American Foundation for Suicide Prevention (AFSP) shows the highest suicide rate was among people 45 to 64 years old and the second highest rate occurred in those 85 years and older. White men over the age of 85 were at the greatest risk of all age, gender, and race groups, reports the Center For Elderly Suicide Prevention.
North Dakota is on target with those national averages. In 2014, the North Dakota Department of Health reports 27 people aged 45 to 54 and an additional 27 people aged 55 to 64 died by suicide. Eleven people aged 65 and over killed themselves. That’s an increase in every age group over the previous year.

“Suicide with adults ages 65 and older is not talked about as much as compared to younger people, but it’s significantly more than people realize,” says Alison Traynor, Suicide Prevention Program Director with the North Dakota Department of Health.

Those are just the reported suicides. The American Association for Marriage and Family Therapy states that “elder suicide may be under-reported by 40 percent or more. Not counted are silent suicides, like deaths from overdoses, self-starvation or dehydration, and [so-called] accidents.”
Part of the reason these rates are so high is because the aging population has a high rate of completing suicide. For young people, one in 25 suicide attempts results in death. But, according to the AFSP, roughly one in four suicide attempts in the elderly ends in death. Older people don’t merely attempt to kill themselves, they execute it—often by the grimmest means necessary. Firearms, hanging, and drowning are the most used methods; double-suicide (or murder-suicide) happens most frequently among the aged.

“Suicide is not a spontaneous decision for aging people; they’ve been thinking about it,” explains Mandy Bernardy, Outpatient Therapist and Licensed Independent Clinical Social Worker at The Village Family Service Center in Moorhead, Minn.

Combination of Things
Bernardy has been counseling families for the past eight years and says about 25 percent of her practice is the aging population. She says suicide rates among the elderly in North Dakota and Minnesota are comparable to national statistics. The reasons why the aging population is at risk for suicide is complex and subject to ongoing research, but there is a cluster of several key risk factors, including depression, physical health or pain, chronic diseases, loss of independence, fear of becoming a burden, financial pressure or concerns, loneliness from having loved ones pass away, and dependence on alcohol or prescription medications.

“There is not just one thing that makes a person contemplate suicide,” says Bernardy. “It’s usually a combination of things.”

Depression is often misunderstood, and if left untreated, can turn into a major risk factor for suicide attempts and completions in older adults. “Depression is more than just sadness,” says Traynor. “Depression and suicidal ideation are not a normal part of aging.”

One of the factors that contributes to depression later in life is the lack of fulfillment people may feel as they age. Physical ailments, chronic pain, financial stresses, and the inability to work can all lead to low self-esteem and low self-worth. Many of these folks have spent a good part of their lives providing for themselves and others. Then, as they start to age, they become increasingly dependent on others and frustrations begin to mount. Maybe they can’t exercise or do their favorite activity—even something as simple as holding cards—anymore. Maybe they’ve lost the ability to concentrate during social gatherings or their eyesight has degenerated to the point where they can no longer drive or read the newspaper. Maybe they’re on a fixed income and worry about how their family will support them as the aging process deepens.

“Feelings of physical and vocational uselessness and financial difficulty can contribute to low self-esteem, hopelessness, and depression,” warns Traynor.

Suck It Up Mentality
North Dakota and western Minnesota have other risk factors unique to their location and culture that contribute to later-life suicide. They are rural and conservative in their approach to mental health issues.

Traynor says studies prove rural communities have more suicides per 100,000 people than larger metropolises. “Some studies have suggested this is linked to rural individuals’ access to firearms, but I’d say the argument is just as strong or stronger that it’s linked to access to mental health services and that sense of isolation,” she clarifies. “And I don’t think it’s been definitively proven either way. All of those together certainly create a perfect storm.”

Traynor and Bernardy both agree people in North Dakota and western Minnesota, regardless of age, are less comfortable with the idea of mental illness and mental health services. A pervasive stigma still exists that those who seek out mental health services are crazy or weak. These stigmatized beliefs are particularly prevalent among aging populations, and as a result, there is a direct link between that line of thinking and people’s comfort level with seeking out mental health services.
It’s one of the biggest barriers to ensuring older loved ones are safe and getting the care they need, says Bernardy. “I believe that people in the elderly population in our region attach this stigma, this ‘suck it up’ mentality, to their personal lives where they want to keep everything private,” she says. “It makes it really difficult for these people to seek services or talk to family.”

Brief Therapy Beneficial
Once (or if) an older person decides to seek help, there can be additional stumbling blocks. The age gap between therapists or counselors and patients may be uncomfortable and lead to resentment. Trust is a huge challenge to overcome in any patient-therapist relationship, but it’s exacerbated when an age, and presumably life, gap is thrown into the mix.

“I run into this all the time,” says Bernardy. “I’m not 55-plus, so for them to understand that I have the experience and education to back what I’m telling them can be hard. It’s so easy for them to look at me as this young kid who doesn’t know anything about the elderly.”

Bernardy says she is sensitive to this and employs more traditional counseling methods when meeting with older patients. “I forego all technology. I have the capability to type while I listen or talk, but to them, this can come across as disrespectful,” she says. “So, mostly I just listen. If I do need to write something down, I do it by hand. I really try to stay where they’re at in the moment.”
Insurance is another headache. Medicaid is the nation’s main public health insurance program for people with low income and the single largest source of public health coverage in the U.S., covering nearly 70 million Americans. Sixteen million of those enrollees are elderly (aged 65 or over) or have disabilities. Unless a Medicaid enrollee has an independent supplemental policy that enhances mental health services coverage, an older person on Medicaid has limited mental health services resources and coverage. “Medicaid only accepts certain kinds of licensures, so if they opened that up a little bit, that would increase access to mental health professionals for people,” explains Bernardy. “There is already a shortage of service providers in Fargo-Moorhead to meet the needs of everyone.”
North Dakota is working diligently to combat the stigma associated with suicide and mental health issues. In the fall, the state’s Department of Health will launch a large-scale media campaign to increase awareness and education on suicide prevention. Unlike campaigns of the past, this one promises to encompass all age groups and will take a targeted approach, says Traynor.

“We’re going to roll out radio, television, billboards, web, and all types of media,” Traynor says. “My hope is that we can use some research and find out the most effective messaging for each age group. And then we can deliver that message specifically to those age groups. Like using radio station demographics, for instance.”

One message Bernardy says has worked well in her practice is to remind older patients that therapy doesn’t have to be forever. So many of her older patients who are dealing with depression or feelings of isolation and low self-esteem think they’re losing their minds and that it will only get worse from there. That’s when thoughts of suicide can really start to take hold. But Bernardy is quick to remind them—or their family members—that therapy offers help now, and isn’t a long-term commitment. “Research shows that even brief therapy is beneficial for people struggling with depression or suicidal thoughts,” she says. “It is something you can overcome, no matter how old you are.”
Depression and other mental health challenges are treatable. Tell someone. Reach out for support—24/7 resources exist. For information on counseling services, The Village Family Service Center can help. Call 701-451-4900. If you or someone you know is in crisis, call 1-800-273-TALK (8255) to contact the National Suicide Prevention Lifeline.

Formerly from Fargo-Moorhead, freelance writer Patricia Carlson writes about baby boomers, parenting, and healthy lifestyles for magazines across the country. Check out her work at www.patriciacarlsonfreelance.com.